LANSING, MICH. — With one in five Medicare patients returning to the hospital within 30 days of release, the U.S. government has implemented financial penalties on high readmittance hospitals in an effort to reduce the staggering number of people returning to hospitals and to curb the $17 billion annual cost associated with preventable readmissions. Seeking to address this problem at its root, the Centers for Medicare & Medicaid Services (CMS) Innovation Center has developed the Community-based Care Transitions Program (CCTP), which awards funding to successful models aimed at reducing hospital readmissions for high-risk patients receiving Medicare.

Currently, more than 100 different community-based organizations across the nation have been coordinating efforts to bring the CCTP to their local area, including the Tri-County Office on Aging in Lansing, Mich. In June 2013, the federally funded CCTP was officially introduced in Lansing, successfully partnering area hospitals, community organizations, state-run offices and a leading provider of in-home care services—Right at Home—to help curb hospital readmissions.

“The readmission rate in the Lansing area has been consistently above 20 percent amongst the Medicare population, which is very high,” Matt Hedberg, owner of Right at Home’s Lansing office, said. “If we have the opportunity to really collaborate with other healthcare organizations and work together as a community, we should be able to decrease that number.

”But for Hedberg and the rest of the CCTP partners, implementing a successful model for hospital exit care is more than just a numbers game; rather, “It’s about keeping people out of the hospital, in their homes, happy and healthy,” Hedberg said.

The CCTP is based on the Bridge Model of Transitional Care, a model drawing on social work concepts and competencies that focus on the complex needs of older adults. Once an eligible patient is ready for discharge from the hospital, the Bridge Care coordinators first assess the level of care needed for the patient and then create a comprehensive continued care plan, which includes in-home assistance from Right at Home.

Lansing’s Tri-County Office on Aging is currently partnered with two regional hospitals, Edward W Sparrow Hospital and McLaren Greater Lansing Hospital, and the Capital Area Collaborative for Care Transitions (CACCT) to serve Medicare beneficiaries residing in Clinton, Eaton and Ingham counties in mid-Michigan.

Funding from the CCTP has been allocated to staff full-time coordinators at participating hospitals to oversee the program, as well as to find community partners like Right at Home that can help provide a full care plan for patients.

“These types of community collaborations are necessary for helping at-risk patients stay out of the hospital,” Hedberg said. “The CCTP allows all the different elements of care—evaluating, planning and implementing—to work together, and ultimately, to help keep people healthy after leaving the hospital.”

Right at Home has been instrumental in providing transportation, medication reminders and social support for discharged patients. The home care company has established a reputation as a leader in the industry, as similar government-funded programs have previously found success in Winston-Salem, N.C., Wake County, N.C., and Durham-Chapel Hill, N.C. Right at Home has also implemented similar hospital transition care plans nationally through their RightTransitions program.

“If we can keep people out of the hospital, everyone saves,” Hedberg said. “In both the local and national healthcare arena, Right at Home is in a position where we can actively be a part of the solution to the problem of hospital readmission.”